Frequently asked questions

Choosing and enrolling

Your employer can help you find a plan that fits your personal needs. You also can check out this article from BCBSRI’s The Rhode Ahead. It tells you what to consider when choosing.

How to make the most of your plan

You can enroll or change your plan during your organization’s annual open enrollment period, which will be announced by your employer.

If you just got married, had a baby, or experienced some other major change, speak with your HR department to make a change in your plan.

Please consult with your Human Resources department for assistance signing up. They can help you choose the right plan, help you with your enrollment form, and answer all of your questions.

Using your benefits

Use find a doctor to search for a "PCP" near you.

Check with your HR department for forms specific to your plan. Otherwise, we have collected almost any form you will need on our forms page.

Your BCBSRI member ID card shows your doctor and other providers that you’re part of the nation’s most trusted health plan. It includes information about your plan and much more. See what everything on your card means, and find answers to common questions.

Your ID card

BCBSRI has shown its commitment to personal help by opening Your Blue Stores in East Providence, Lincoln, and Warwick. All members can ask questions, get answers, and join no-cost fitness and education classes. Locate a store near you.

Yes. As a BCBSRI member, you can receive the lowest available membership rate offered by thousands of participating gyms nationwide. Call 1-800-866-8466.

You also can take exercise classes at no cost at Your Blue Store locations. Check the schedules.

Log in to your online account and you will see a button that says “Go to My Pharmacy Benefits Manager.”

Log in

Log in to your online account and you will see a section titled “Claims.”

Log in

Other common topics

View Benefits in your online account, as well as Subscriber Agreements, to view your plan benefits and services. For questions about your coverage, please refer to your subscriber agreement/benefit booklet or call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI).

There are certain limitations and exclusions to your Blue Cross policy. For example, Blue Cross plans generally do not cover cosmetic surgery, long-term care, custodial care, weight-loss programs, and routine foot care (unless there are systemic conditions). For a complete list of covered benefits and exclusions, view Benefits in your online account, as well as Subscriber Agreements, to view your plan benefits and services. For questions about your coverage, please refer to your subscriber agreement/benefit booklet or call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI).

To learn more about the costs you may have to pay, log in to your online account. For questions about your coverage, please refer to your subscriber agreement/benefit booklet, ask your employer, or call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI).

In addition, you can view our Insurance 101 section to help you understand the basics of a health plan. Our Definitions page provides easy-to-understand explanations of key insurance terms like deductible, coinsurance, and out of pocket.

If you need help finding a primary care provider, other doctor, or a hospital/facility, you can use the Find a Doctor tool or call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI). You can get information such as board certification status, languages spoken by the doctor, and whether the office is wheelchair accessible. If you’re using the find a doctor tool, you can even print out directions to the doctor’s office. Please note: If you have a question about a doctor that Customer Service can’t answer right away, they will get back to you with an answer. This includes questions on education, training, residency completed, board certification, and specialty.

While you may not be required to select a primary care provider, these practitioners can assist you in maintaining and monitoring your health and accessing the services of specialty care physicians.

Depending on your plan, you may need a referral from your primary care physician (PCP) to see a specialist. (Read Do you need a referral for more information.) But even if you don't need a referral, it's a good idea to ask your PCP for a recommendation about which doctor to see. He or she may even be able to set up an appointment for you. Hospital services are usually arranged for you by your physician and may require preauthorization (approval of services in advance).

You can save money by getting specialty care and behavioral healthcare from within the Blue Cross network. Participating providers and facilities are listed on our find a doctor tool.

If you need care after hours or when your primary care provider (PCP) is not available, if it is not an emergency you should still call your PCP's office. PCPs make arrangements for 24-hour coverage so you can get the care you need even if they're not personally available. When you call, you'll be put in touch with your doctor or the on-call doctor. For more information, see Your Guide to Care Beyond the Doctor's Office.

Important note: If you are having a medical emergency, call 911, not your doctor! See your Member Handbook for information on emergency care.

Many Blue Cross plans offer specific levels of healthcare benefits wherever you live or travel, across the country and worldwide. Blue Cross participates in the BlueCard Program, which enables you to access the BlueCard national network if you need care when away from home. You can ask your employer or call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI) to verify your benefits and for additional assistance, or you can call 1-800-810-Blue (2583). BlueCard provides the name and location of participating BlueCard PPO doctors and hospitals. You can also locate a doctor anytime by visiting:

Find a doctor

For information about out-of-area coverage and restrictions for care outside of Rhode Island, please:

  • see your Member Handbook
  • or refer to your plan benefits by logging in to your online account and checking your subscriber agreement/benefit booklet
  • or call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI)

If you have prescription drug coverage through Blue Cross, you can find everything you need to manage and maximize your coverage by logging in to your online account and choosing "Go to My Pharmacy Benefits Manager" on your home page. From this page, you can:

  • View your pharmacy benefits and prescription drug history
  • Sign up to receive maintenance drugs through the mail
  • Find information about quantity limits, step therapy, and other management programs
  • View the covered drug list (formulary)
  • Save money with generic drugs
  • Find information about the medical formulary exception process
  • Determine a drug's common side effects, significant risks, and potential interactions
  • Find the copay of prescription drugs to be filled at a retail pharmacy
  • Find a pharmacy and get door-to-door directions
  • Get the most frequently requested forms and documents
  • Know which prescriptions require special paperwork from your provider

Our medical director and the Medical Policy Department continually review new medical technologies and treatments to decide if they should be covered. Blue Cross also follows guidelines established by the Blue Cross and Blue Shield Association and national guidelines.

As a Blue Cross member, you are a partner in your health — both with your doctor and with Blue Cross. That’s why it’s important to understand your rights and responsibilities. Refer to your Member Handbook for a complete listing of your member rights and responsibilities.

Blue Cross's Grievances and Appeals Unit is here to provide a thorough, timely, and unbiased review of complaints and administrative and medical appeals. The purpose of this process is to ensure that benefits are administered equitably (fairly and equally) according to member contracts, regulatory mandates, accrediting standards, and Blue Cross policies. To see how to voice a complaint or appeal a decision that negatively affected your coverage, benefits, or your relationship with us, please refer to your Member Handbook.

For your convenience, there are virtually no claim forms for you to file when you seek care from in-network providers and show your member ID card. The provider will process your claims directly with us, so you don't need to handle any paperwork. We then reimburse the provider.

If your plan covers services from a non-network provider, you may have to pay the non-network provider for the service and then file a claim with us for reimbursement. Please refer to your Member Handbook for more detail on filing claims.

If you have any questions about when you may need to file a claim with us, call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI).

Read about our Language Assistance.

To receive language assistance, call Customer Service at (401) 459-5000 or 1-800-639-2227 (outside RI).

If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. You can read the Chronic diseases & conditions page of this website or your Member Handbook to learn more about the tools and information available to help you manage your condition and improve your health.

Care Coordination provides support for members with chronic (for example, asthma or diabetes), complex, or catastrophic (very serious) conditions. You can read the Chronic diseases & conditions page of this website or your Member Handbook to learn more about this program.

The Quality Management (QM) Program ensures that our members experience the best health outcomes possible when receiving physical and behavioral healthcare services. This includes collaborating with our provider network to focus on the safety of our members’ care. By continually working to improve quality, the QM Program establishes high standards of evidence-based medical practice in the community, prioritizes member health and safety, and works to improve member and provider satisfaction. This process helps ensure our members receive high-quality care that improves their health. It also positively impacts the health of our community. The Blue Cross QM Program goals are to:

  • Perform quality improvement and assurance activities in alignment with our corporate mission, goals, and strategies
  • Improve quality, safety, and coordination of care for our members receiving physical and behavioral healthcare services
  • Integrate physical and behavioral healthcare to improve the quality of care delivered to our members
  • Continuously promote and monitor evidence-based best medical practice across our network of providers
  • Collaborate with community partners to achieve improved care for all Blue Cross members
  • Improve the quality of member and provider engagement and satisfaction with the health plan, including access to care
  • Identify our members’ varied cultural and linguistic needs to offer a diverse range of services, which provide meaningfully improved care to our members and support our providers’ care for members
  • Improve the cost, quality, and efficiency of service delivered to members and providers

Members can view the Goals of the QM Programand our progress toward meeting these goals in the annual QM Program Evaluation.

Blue Cross is committed to providing integrated, high-quality services while enhancing the safety of our members and providers. Member safety initiatives proactively identify and evaluate issues related to patient safety for both physical and behavioral healthcare. Blue Cross helps foster an environment that allows all providers (of physical and behavioral healthcare) to improve the safety of their practices and the quality and coordination of care they deliver. BCBSRI has implemented several initiatives to improve the safety and care our members receive, including our:

  • Hospital Quality Program, which helps improve the quality, safety, and efficiency of care provided in local hospitals
  • Skilled Nursing Facilities Quality Program, which aims to improve the outcomes of our members receiving care in skilled nursing facilities
  • Transitions of Care Program, which helps patients safely transition from the hospital to home and reduces hospital readmissions
  • Process for reviewing quality of care complaints, which can be found in your Member Handbook.

You have the right to view or get copies of your personal health information used by our health plan to make decisions about payment for your healthcare. To view or copy your records, you must submit your request to us in writing. We will provide a release of information form for you to complete and send to us with your request. Our Notice of Privacy Practices provides detailed information on your privacy rights, including how to submit a request to us in writing.

Blue Cross employees and agents protect the privacy and confidentiality of our members' healthcare information through administrative, technical, and physical safeguards. We maintain, use, and disclose confidential health information as permitted or required by applicable state and federal laws, such as the Rhode Island Confidentiality of Health Care Communications and Information Act, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Privacy and Security Regulations of HIPAA require us to implement specific safeguards to protect the privacy of our members’ health information, in both printed and electronic formats. You can learn more about these safeguards in the Member Handbook, in our Protecting Your Information presentation, or the Notice of Privacy Practices.

Did you know that you may be required to get prior approval from Blue Cross for certain medical services or procedures? This is called preauthorization and it helps you:

  • Find out if you’re covered by your benefits before you have your scheduled procedure
  • Save money and avoid extra costs
  • Estimate your out-of-pocket costs before you get your service
  • Avoid unnecessary services

Learn more about the preauthorization process in your Member Handbook.

All utilization review decisions are based only on appropriateness of care, service, existence of coverage, and setting of the covered service. Please note:

  • We do not use financial incentives in conjunction with our Utilization Management Program.
  • We do not reward doctors who conduct utilization review for issuing denials of coverage or service.
  • We do not offer financial incentives to utilization management decision makers that encourage decisions resulting in underutilization.

To request preauthorization or other utilization management matters, please call the Utilization Management Department at (401) 272-5670 or 1-800-635-2477 (outside of Rhode Island only) during normal business hours: Monday through Friday, 8:00 a.m. to 4:30 p.m. TTY/TDD (Telecommunications Device for the Deaf) services are available by calling 1-888-252-5051 during normal business hours. If you need interpreter services to discuss utilization management matters, please ask one of our representatives about using an interpreter. After hours, if it is a non-urgent matter, you will be directed to leave a brief message with your name and number. Your call will be returned the next business day.

As part of our Utilization Management Program, members have the right to appeal our review decisions. You can find information about our Utilization Management Program in your Member Handbook.